Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
European Spine Journal
Published in: European Spine Journal 3/2007

01-03-2007 | Review

A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy

Authors: Sidney M. Rubinstein, Jan J. M. Pool, Maurits W. van Tulder, Ingrid I. Riphagen, Henrica C. W. de Vet

Published in: European Spine Journal | Issue 3/2007

Login to get access

Abstract

Clinical provocative tests of the neck, which position the neck and arm inorder to aggravate or relieve arm symptoms, are commonly used in clinical practice in patients with a suspected cervical radiculopathy. Their diagnostic accuracy, however, has never been examined in a systematic review. A comprehensive search was conducted in order to identify all possible studies fulfilling the inclusion criteria. A study was included if: (1) any provocative test of the neck for diagnosing cervical radiculopathy was identified; (2) any reference standard was used; (3) sensitivity and specificity were reported or could be (re-)calculated; and, (4) the publication was a full report. Two reviewers independently selected studies, and assessed methodological quality. Only six studies met the inclusion criteria, which evaluated five provocative tests. In general, Spurling’s test demonstrated low to moderate sensitivity and high specificity, as did traction/neck distraction, and Valsalva’s maneuver. The upper limb tension test (ULTT) demonstrated high sensitivity and low specificity, while the shoulder abduction test demonstrated low to moderate sensitivity and moderate to high specificity. Common methodological flaws included lack of an optimal reference standard, disease progression bias, spectrum bias, and review bias. Limitations include few primary studies, substantial heterogeneity, and numerous methodological flaws among the studies; therefore, a meta-analysis was not conducted. This review suggests that, when consistent with the history and other physical findings, a positive Spurling’s, traction/neck distraction, and Valsalva’s might be indicative of a cervical radiculopathy, while a negative ULTT might be used to rule it out. However, the lack of evidence precludes any firm conclusions regarding their diagnostic value, especially when used in primary care. More high quality studies are necessary in order to resolve this issue.
Appendix
Available only for authorised users
Literature
1.
DJ Magee (ed) (1997) Cervical spine. In: Orthopedic physical assessment, 3rd edn. W.B. Saunders, Philadelphia, pp 101–151
2.
R Evans (ed) (2001) Cervical spine. In: Illustrated orthopedic physical assessment, 2nd edn. C.V. Mosby, St. Louis
3.
AN de Wolf, JMA Mens (eds) (2001) De cervicale wervelkolom. In: Onderzoek van het bewegingsapparaat. Fysische diagnostiek in de algemene praktijk. Derde, Derde edn. Bohn, Stafleu, van Loghn, Houten/Diegem, The Netherlands, pp 137–156
4.
Abdulwahab SS, Sabbahi M (2000) Neck retractions, cervical root decompression, and radicular pain. J Orthop Sports Phys Ther 30(1):4–9PubMed
5.
Ahlgren BD, Garfin SR (1996) Cervical radiculopathy. Orthop Clin North Am 27(2):253–263PubMed
6.
Albeck MJ (1996) A critical assessment of clinical diagnosis of disc herniation in patients with monoradicular sciatica. Acta Neurochir (Wien) 138(1):40–44CrossRef
7.
American Association of Electrodiagnostic Medicine (1999) Guidelines in electrodiagnostic medicine, Chap 9. The electrodiagnostic evaluation of patients with suspected cervical radiculopathy: literature review on the usefulness of needle electromyography. Muscle Nerve 22(Suppl 8):S213–S221
8.
American Association of Electrodiagnostic Medicine (1999) Practice parameter for needle electromyogrphic evaluation of patients with suspected cervical radiculopathy: summary statement. Muscle Nerve 22(Suppl 8):S209–S211
9.
10.
Bachmann LM, Coray R, Estermann P, Ter Riet G (2002) Identifying diagnostic studies in MEDLINE: reducing the number needed to read. J Am Med Inform Assoc 9(6):653–658PubMedCrossRef
11.
Bartlett RJ, Hill CA, Devlin R, Gardiner ED (1996) Two-dimensional MRI at 1.5 and 0.5 T versus CT myelography in the diagnosis of cervical radiculopathy. Neuroradiology 38(2):142–147PubMedCrossRef
12.
Bartlett RJ, Hill CR, Gardiner E (1998) A comparison of T2 and gadolinium enhanced MRI with CT myelography in cervical radiculopathy. Br J Radiol 71(841):11–19PubMed
13.
Bednar MS, Light TR (2003) Hand surgery. In: HB Skinner (ed) Current diagnosis and treatment in orthopedics, 3rd edn. Lange Medical Books/McGraw-Hill, New York, pp 525–588
14.
Bendszus M, Wessig C, Reiners K et al (2003) MR imaging in the differential diagnosis of neurogenic foot drop. AJNR Am J Neuroradiol 24(7):1283–1289PubMed
15.
Birchall D, Connelly D, Walker L, Hall K (2003) Evaluation of magnetic resonance myelography in the investigation of cervical spondylotic radiculopathy. Br J Radiol 76(908):525–531PubMedCrossRef
16.
Bland JH (1987) Clinical methods. In: Bland J.H. (ed) Disorders of the cervical spine. Diagnosis and medical management. W.B. Saunders, Philadelphia, pp 79–112
17.
Boden SD, McCowin PR, Davis DO et al (1990) Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 72(8):1178–1184PubMed
18.
Carette S, Fehlings MG (2005) Clinical practice. Cervical radiculopathy. N Engl J Med 353(4):392–399PubMedCrossRef
19.
Coppieters M, Stappaerts K, Janssens K, Jull G (2002) Reliability of detecting ‘onset of pain’ and ‘submaximal pain’ during neural provocation testing of the upper quadrant. Physiother Res Int 7(3):146–156PubMedCrossRef
20.
Daniels DL, Grogan JP, Johansen JG et al (1984) Cervical radiculopathy: computed tomography and myelography compared. Radiology 151(1):109–113PubMed
21.
Davidson RI, Dunn EJ, Metzmaker JN (1981) The shoulder abduction test in the diagnosis of radicular pain in cervical extradural compressive monoradiculopathies. Spine 6(5):441–446PubMedCrossRef
22.
Eisen A (1991) The utility of proximal nerve conduction in radiculopathies: the cons. Electroencephalogr Clin Neurophysiol 78(3):171–172PubMedCrossRef
23.
Ellenberg MR, Honet JC, Treanor WJ (1994) Cervical radiculopathy. Arch Phys Med Rehabil 75(3):342–352PubMedCrossRef
24.
Elvey RL (1994) The investigation of arm pain: signs of adverse responses to the physical examination of the brachial plexus, related tissues. In: Boyling JD, Palastanga N (eds) Grieve’s modern manual therapy, 2nd edn. Churchill Livingstone, New York, pp 577–585
25.
Fast A, Parikh S, Marin EL (1989) The shoulder abduction relief sign in cervical radiculopathy. Arch Phys Med Rehabil 70(5):402–403PubMed
26.
Friedenberg Z, Miller W (1963) Degenerative disc disease of the cervical spine. J Bone Joint Surg Am 45:1171–1178PubMed
27.
Han JJ, Kraft GH (2003) Electrodiagnosis of neck pain. Phys Med Rehabil Clin N Am 14(3):549–567PubMed
28.
Honet JC, Ellenberg MR (2003) What you always wanted to know about the history and physical examination of neck pain but were afraid to ask. Phys Med Rehabil Clin N Am 14(3):473–491PubMed
29.
Jonsson B, Stromqvist B (1995) The straight leg raising test and the severity of symptoms in lumbar disc herniation. A preoperative evaluation. Spine 20(1):27–30PubMed
30.
Katirji MB, Agrawal R, Kantra TA (1988) The human cervical myotomes: an anatomical correlation between electromyography and CT/myelography. Muscle Nerve 11(10):1070–1073PubMedCrossRef
31.
Kelsey JL (1978) Epidemiology of radiculopathies. Adv Neurol 19:385–398PubMed
32.
Kleinrensink GJ, Stoeckart R, Mulder PG et al (2000) Upper limb tension tests as tools in the diagnosis of nerve and plexus lesions. Anatomical and biomechanical aspects. Clin Biomech (Bristol, Avon ) 15(1):9–14CrossRef
33.
Kosteljanetz M, Bang F, Schmidt-Olsen S (1988) The clinical significance of straight-leg raising (Lasegue’s sign) in the diagnosis of prolapsed lumbar disc. Interobserver variation and correlation with surgical finding. Spine 13(4):393–395PubMedCrossRef
34.
Larsson EM, Holtas S, Cronqvist S, Brandt L (1989) Comparison of myelography, CT myelography and magnetic resonance imaging in cervical spondylosis and disk herniation. Pre- and postoperative findings. Acta Radiol 30(3):233–239PubMedCrossRef
35.
Lindgren KA, Leino E, Manninen H (1992) Cervical rotation lateral flexion test in brachialgia. Arch Phys Med Rehabil 73(8):735–737PubMed
36.
Malanga GA, Landes P, Nadler SF (2003) Provocative tests in cervical spine examination: historical basis and scientific analyses. Pain Physician 6:199–205PubMed
37.
Malanga G, Landes P, Nadler S (2003) Provocative tests in cervical spine examination: historical basis and scientific analyses. Pain Physician 6:199–205PubMed
38.
Modic MT, Masaryk TJ, Mulopulos GP et al (1986) Cervical radiculopathy: prospective evaluation with surface coil MR imaging, CT with metrizamide, and metrizamide myelography. Radiology 161(3):753–759PubMed
39.
Negrin P, Lelli S, Fardin P (1991) Contribution of electromyography to the diagnosis, treatment and prognosis of cervical disc disease: a study of 114 patients. Electromyogr Clin Neurophysiol 31(3):173–179PubMed
40.
Partanen J, Partanen K, Oikarinen H, Niemitukia L, Hernesniemi J (1991) Preoperative electroneuromyography and myelography in cervical root compression. Electromyogr Clin Neurophysiol 31(1):21–26PubMed
41.
Pepe MS, Janes H, Longton G, Leisenring W, Newcomb P (2004) Limitations of the odds ratio in gauging the performance of a diagnostic, prognostic, or screening marker. Am J Epidemiol 159(9):882–890PubMedCrossRef
42.
Quintner JL (1989) A study of upper limb pain and paraesthesiae following neck injury in motor vehicle accidents: assessment of the brachial plexus tension test of Elvey. Br J Rheumatol 28(6):528–533PubMedCrossRef
43.
Radhakrishnan K, Litchy WJ, O’Fallon WM, Kurland LT (1994) Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain 117(Pt 2):325–335PubMedCrossRef
44.
Reilly PA, Littlejohn GO (1990) The brachial plexus tension test of Elvey. Br J Rheumatol 29(3):234–235PubMedCrossRef
45.
46.
Sandmark H, Nisell R (1995) Validity of five common manual neck pain provoking tests. Scand J Rehabil Med 27(3):131–136PubMed
47.
Schwartzman RJ (1991) Brachial plexus traction injuries. Hand Clin 7(3):547–556PubMed
48.
Selvaratnam PJ, Matyas TA, Glasgow EF (1994) Noninvasive discrimination of brachial plexus involvement in upper limb pain. Spine 19(1):26–33PubMedCrossRef
49.
Shacklock MO (1996) Positive upper limb tension test in a case of surgically proven neuropathy: analysis and validity. Man Ther 1(3):154–161PubMedCrossRef
50.
Shafaie FF, Wippold FJ, Gado M, Pilgram TK, Riew KD (1999) Comparison of computed tomography myelography and magnetic resonance imaging in the evaluation of cervical spondylotic myelopathy and radiculopathy. Spine 24(17):1781–1785PubMedCrossRef
51.
Shah KC, Rajshekhar V (2004) Reliability of diagnosis of soft cervical disc prolapse using Spurling’s test. Br J Neurosurg 18(5):480–483PubMedCrossRef
52.
Spengler DM, Freeman CW (1979) Patient selection for lumbar discectomy. An objective approach. Spine 4(2):129–134PubMedCrossRef
53.
Spengler DM, Ouellette EA, Battie M, Zeh J (1990) Elective discectomy for herniation of a lumbar disc. Additional experience with an objective method. J Bone Joint Surg Am 72(2):230–237PubMed
54.
Spurling RG, Scoville WB (1944) Lateral rupture of the cervical intervertebral discs: a common cause of shoulder and arm pain. Surg Gynecol Obstet 78:350–358
55.
Sterling M, Treleaven J, Jull G (2002) Responses to a clinical test of mechanical provocation of nerve tissue in whiplash associated disorder. Man Ther 7(2):89–94PubMedCrossRef
56.
Stratton SA, Bryan JM (1989) Dysfunction, evaluation, and treatment of the cervical spine and thoracic inlet. In: Donatelli R, Wooden MJ (eds) Orthopaedic physical therapy. Churchill Livingstone, New York, pp 71–108
57.
Sweeney PJ (1995) Clinical evaluation of cervical radiculopathy and myelopathy. Neuroimaging Clin N Am 5(3):321–327PubMed
58.
Teresi LM, Lufkin RB, Reicher MA et al (1987) Asymptomatic degenerative disk disease and spondylosis of the cervical spine: MR imaging. Radiology 164(1):83–88PubMed
59.
Tong HC, Haig AJ, Yamakawa K (2002) The Spurling test and cervical radiculopathy. Spine 27(2):156–159PubMedCrossRef
60.
Uchihara T, Furukawa T, Tsukagoshi H (1994) Compression of brachial plexus as a diagnostic test of cervical cord lesion. Spine 19(19):2170–2173PubMedCrossRef
61.
Viikari-Juntura E (1987) Interexaminer reliability of observations in physical examinations of the neck. Phys Ther 67(10):1526–1532PubMed
62.
Viikari-Juntura E, Porras M, Laasonen EM (1989) Validity of clinical tests in the diagnosis of root compression in cervical disc disease. Spine 14(3):253–257PubMedCrossRef
63.
Wainner RS, Fritz JM, Irrgang JJ et al (2003) Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine 28(1):52–62PubMedCrossRef
64.
Wetzel FT, Reider B (2005) Cervical and thoracic spine. In: B Reider (eds) The orthopaedic physical exam. 2nd edn. Elsevier Saunders, Philadelphia, pp 297–334
65.
Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J (2003) The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 3(1):25PubMedCrossRef
Metadata
Title
A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy
Authors
Sidney M. Rubinstein
Jan J. M. Pool
Maurits W. van Tulder
Ingrid I. Riphagen
Henrica C. W. de Vet
Publication date
01-03-2007
Publisher
Springer-Verlag
Published in
European Spine Journal / Issue 3/2007
Print ISSN: 0940-6719
Electronic ISSN: 1432-0932
DOI
https://doi.org/10.1007/s00586-006-0225-6

Other articles of this Issue 3/2007

European Spine Journal 3/2007 Go to the issue

Ideas and Technical Innovations

Percutaneous endoscopic lumbar discectomy for migrated disc herniation: classification of disc migration and surgical approaches

Original Article

Minimum 10 years follow-up surgical results of adolescent idiopathic scoliosis patients treated with TSRH instrumentation

Original Article

The development of an evidence-based patient booklet for patients undergoing lumbar discectomy and un-instrumented decompression

Editorial

Alf Nachemson, MD, PhD, 1931–2006: an exceptional pioneer in spine care

Original Article

MW construct in fusion for neuromuscular scoliosis

Original Article

Results of brace treatment of adolescent idiopathic scoliosis in boys compared with girls: a retrospective study of 102 patients treated with the Boston brace